Clinical Manual for Management of the HIV-Infected ... - myCME.com

Neurologic Symptoms
Background
The nervous system may be a site of complications
throughout the course of HIV infection, and neurologic
complaints are common in people living with HIV/
AIDS. Neurologic symptoms may be caused by
many factors, including infections (opportunistic and
other), central nervous system (CNS) malignancies,
medication toxicities, comorbid conditions (eg, diabetes,
cerebrovascular disease, chronic hepatitis, mental
illness), and nervous system injuries related to HIV
itself.
The risk of some conditions, such as CNS infection,
malignancy, and dementia, increases with advancing
immunosuppression, and the CD4 cell count will help
to stratify the patient’s risk of opportunistic illnesses
(see Table 1 in chapter CD4 Monitoring and Viral
Load Testing). This chapter presents a general approach
to neurologic symptoms in HIV-infected patients,
with reference to other chapters in this manual for
more detailed reading. For information on peripheral
neuropathy, see chapter Pain Syndrome and Peripheral
Neuropathy.
S: Subjective
The patient, or a friend or family member on his or her
behalf, reports new neurologic symptoms such as pain,
headache, seizures, altered mental status, or weakness.
Ascertain the following during the history:
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Onset and duration: rapid (hours to days), subacute,
chronic
Characteristics of the symptoms (eg, location,
quality, timing)
Progression or stability of symptoms
Constitutional symptoms: fever, night sweats,
unintentional weight loss
Associated symptoms, including other neurologic,
muscular, psychiatric, or behavioral symptoms
Recent trauma to the head or other area
Visual changes, photophobia
Dizziness, vertigo
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Section 5—Complaint-Specific Workups | 5–37
Mental status changes (including changes
in behavior, personality, or cognition; shortterm
memory loss; mental slowing; reading
comprehension difficulties; changes in personal
appearance and grooming habits)
Seizures (description, duration, number)
Pain
Sensory symptoms
Weakness (distinguish weakness from fatigue or
pain; determine whether bilateral or focal, proximal
or distal)
Bowel or bladder changes
Rash or ulcerations
Medications: current, past, and recently initiated
medications, including antiretroviral therapy (ART)
Alcohol or drug use; date of last use
Exposures (sexual, environmental), travel history
Psychiatric history and past psychiatric care
Most recent CD4 cell count and HIV viral load,
previous AIDS-defining illnesses
Functional impact of the symptoms: social
functioning, ability to work and perform activities of
daily living
Differentiate delirium from dementia. Delirium
presents as acute onset of clouded sensorium, disturbed
and fluctuating level of consciousness, disorientation,
cognitive deficits, and reduced attention, sometimes
with hallucinations. Delirium is often due to medication
toxicities, infections, hypoxia, hypoglycemia, electrolyte
imbalances, or mass lesions, and is frequently is
correctable. Dementia emerges more gradually and is
characterized by cognitive impairment and behavioral,
motor, and affective changes. See chapter HIV-Associated
Dementia and Minor Cognitive Motor Disorder.